Limits of the AGA Practice Update for Barrett’s Esophagus Screening: A Proposal for Electronic Health Record–Adaptable Risk Models
Authors: Theresa Nguyen Wenker, Aaron P. Thrift, Hashem B. El-serag
Journal: Clinical Gastroenterology and Hepatology (2022)

Despite multiple practice guidelines recommending screening for Barrett's esophagus (BE) in high-risk patients, adherence in clinical practice is poor. In a meta-analysis, 57% of newly diagnosed esophageal adenocarcinoma (EAC) patients had a concomitant new diagnosis of BE, suggesting prior missed opportunities to screen for BE.1Tan M.C. et al.Aliment Pharmacol Ther. 2020; 52: 20-36Crossref PubMed Scopus (42) Google Scholar Compared with patients with EAC with previously known BE diagnosis, concomitant new diagnosis of BE at the time of EAC is associated with diagnosis at a later stage no longer amenable to cure and a higher EAC mortality.1Tan M.C. et al.Aliment Pharmacol Ther. 2020; 52: 20-36Crossref PubMed Scopus (42) Google Scholar Patients with new diagnosis of BE at time of EAC are also more likely to be diagnosed at a later stage no longer amenable to endoscopic or surgical cure.2El-Serag H.B. et al.Gut. 2016; 65: 1252-1260Crossref PubMed Scopus (105) Google Scholar Current guidelines inadequately link evidence to recommendations and are ambiguous.3Shaheen N.J. et al.Am J Gastroenterol. 2022; 117: 559-587Crossref PubMed Scopus (135) Google Scholar, 4Qumseya B. et al.Gastrointest Endosc. 2019; 90: 335-359Abstract Full Text Full Text PDF PubMed Scopus (243) Google Scholar, 5Muthusamy V.R. et al.Clin Gastroenterol Hepatol. 2022; 20: 2696-2706.e1Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar Recommendations use prose language to allude to high-risk groups with no clear weighting of individual risk factors. This phrasing can perpetuate practices that may be inconsistent or incorrect. For example, the new 2022 American Gastroenterological Association Clinical Practice Update (CPU) has changed the listed risk factors to male, non-Hispanic White, age >50 years, history of smoking, chronic gastroesophageal reflux disease, obesity, or a family history of BE or EAC; and specifies that those with ≥3 of these risk factors should be screened.5Muthusamy V.R. et al.Clin Gastroenterol Hepatol. 2022; 20: 2696-2706.e1Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar There are limitations to the CPU that could hamper its applicability in clinical practice. First, it is assumed that these risk factors have equal weights. In reality, some of these risk factors are common and strong predictors of BE (eg, gastroesophageal reflux disease symptoms), whereas others are not (eg, elevated body mass index). Given that most primary risk factors for BE are common in the population (eg, up to 20% of the adult population in Western countries suffer from weekly reflux symptoms, and approximately 30% are obese and 20% are current smokers), these factors are therefore prevalent in individuals who will not develop BE. Depending on which 3 factors are chosen, the probability of BE varies considerably. Lastly, increased intrabdominal fat is rarely measured in clinical practice. This ambiguity may have substantial implications for practice. In examining the yield of the CPU for diagnosing BE in an unreferred primary care population who underwent study screening esophagogastoduodenoscopy, we found that the 2022 American Gastroenterological Association CPU (ie, presence of any 3+ risk factors) was highly sensitive at 95.5%, which is excellent, but only 7.9% specific (area under the receiver operating characteristic curve of 0.52).5Muthusamy V.R. et al.Clin Gastroenterol Hepatol. 2022; 20: 2696-2706.e1Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar This means that most patients undergoing endoscopy based on this CPU will not have BE, raising concerns about increased costs and possible harm. These limitations are not unique to the American Gastroenterological Association recommendations.6Nguyen T.H. et al.Gastrointest Endosc. 2021; 93: 409-419Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar It becomes that simple rules of thumb are not useful in the presence of multiple risk factors of unequal weights, and that more sophisticated predictive modeling is required. Previous algorithmic models have attempted to operationalize risk factors in BE screening; however, these models are too complex for clinical practice.7Rubenstein J.H. et al.Gastroenterology. 2020; 158: 2082-2092Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar Some of these models are partly based on risk factors obtained from patient surveys or uncommonly obtained physical measurements making them difficult to implement in a busy clinical practice. To circumvent these limitations, we developed and validated a predictive model (the Houston-BEST) that incorporates the joint weighted effect of BE risk factors (sex, age ≥50 years, race/ethnicity, smoking status, body mass index, chronic gastroesophageal reflux disease, and family history of esophageal cancer) that can be obtained from the electronic health record (EHR) to identify patients for BE screening (manuscript accepted). The performance of the Houston-BEST (area under the receiver operating characteristic curve of 0.65–0.70 in validation studies) is at the high end of the published range of area under the receiver operating characteristic curve for other BE risk models (0.58–0.70). However, how do we move models such as this one from an academic exercise into clinical practice? EHR-based electronic trigger (e-trigger) tools mine vast amounts of electronic clinical data and can automatically identify and flag patients who are at risk for a missed medical diagnosis (eg, BE).8Murphy D.R. et al.Clin Gastroenterol Hepatol. 2018; 16: 90-98Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar E-trigger tools can reduce the number of records that require manual review to only those at highest risk of BE. Previously developed EHR-based triggers have been for relatively straightforward applications (eg, abnormal laboratory tests).8Murphy D.R. et al.Clin Gastroenterol Hepatol. 2018; 16: 90-98Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Further work on the development and validation of an e-trigger tool incorporating predictive models to automatically identify patients in need of BE screening can address challenges related to (1) current guideline recommendations that perform poorly, (2) models attempting to improve on guidelines but contain variables that are not readily measurable or available, and (3) predictive models that operate in a platform outside the EHR (eg, online calculators). AGA Clinical Practice Update on New Technology and Innovation for Surveillance and Screening in Barrett's Esophagus: Expert ReviewClinical Gastroenterology and HepatologyVol. 20Issue 12PreviewThe purpose of this best practice advice (BPA) article from the Clinical Practice Update Committee of the American Gastroenterological Association is to provide an update on advances and innovation regarding the screening and surveillance of Barrett's esophagus. Full-Text PDF ReplyClinical Gastroenterology and HepatologyVol. 21Issue 7PreviewWe have read with interest the Letter to the Editor by Wenker et al,1 regarding the limitations of the recent AGA Clinical Practice Update (CPU) for screening and surveillance in Barrett's esophagus (BE).2 We appreciate the concern for overutilization of endoscopic screening based on this document; however, we would like to provide some clarity as to this specific best practice statement and its implications for clinical practice. Full-Text PDF